Provider Demographics
NPI:1063988541
Name:DERMASURGERY SPECIALIST, PLLC
Entity type:Organization
Organization Name:DERMASURGERY SPECIALIST, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAIRA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOMIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-464-5000
Mailing Address - Street 1:2728 MCKINNON ST APT 610
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-1636
Mailing Address - Country:US
Mailing Address - Phone:281-744-6708
Mailing Address - Fax:
Practice Address - Street 1:2020 W STATE HIGHWAY 114 STE 340
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-8650
Practice Address - Country:US
Practice Address - Phone:817-464-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-23
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty